Crosslinked hyaluronic acid dermal fillers: a comparison
of rheological properties
Samuel J. Falcone, Richard A. Berg
FzioMed Inc., 231 Bonetti Drive, San Luis Obispo, California 93401
Received 30 November 2006; revised 20 April 2007; accepted 31 July 2007
Published online 15 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jbm.a.31675
Abstract: Temporary dermal fillers composed of cross-
linked hyaluronic acid (XLHA) are space filling gels that
are readily available in the United States and Europe. Sev-
eral families of dermal fillers based on XLHA are now
available and here we compare the physical and rheologi-
cal properties of these fillers to the clinical effectiveness.
The XLHA fillers are prepared with different crosslinkers,
using HA isolated from different sources, have different
particle sizes, and differ substantially in rheological prop-
erties. For these fillers, the magnitude of the complex vis-
cosity, |h*|, varies by a factor of 20, the magnitude of the
complex rigidity modulus, |G*|, and the magnitude of the
complex compliance, |J*| vary by a factor of 10, the per-
cent elasticity varies from 58% to 89.9%, and the tan d
varies from 0.11 to 0.70. The available clinical data cannot
be correlated with either the oscillatory dynamic or steady
INTRODUCTION
Dermal fillers for cosmesis of the face were intro-
duced many years ago and received a large follow-
ing with the introduction of injectable bovine colla-
gen.1 As the procedures for wrinkle correction with
dermal fillers became more popular, the search
began for safer, longer lasting fillers. The next gener-
ation filler after bovine collagen was crosslinked hy-
aluronic acid (XLHA), which was an improvement
over bovine collagen in that it did not require a skin
test for hypersensitivity and appeared to be longer
lasting.2 The search for safer and more effective der-
mal fillers has continued because patients desire
temporary fillers that are safe and predictably last
longer than 6 months.3,4 In spite of a plethora of
new temporary fillers composed of XLHA that are
available in Europe and are undergoing clinical test-
ing in the United States, it is not understood what
parameters control the performance of these fillers.
Although several studies have demonstrated that
Correspondence to: R. A. Berg; e-mail: raberg@fziomed.com
Ó 2008 Wiley Periodicals, Inc.
flow rotational rheological properties of the various fillers.
However, the clinical data appear to correlate strongly
with the total concentration of XLHA in the products and
to a lesser extent with percent elasticity. Hence, our data
suggest the following correlation: dermal filler persistence
5 [polymer] 3 [% elasticity] and the clinical persistence of
a dermal filler composed of XLHA is dominated by the
mass and elasticity of the material implanted. This work
predicts that the development of future XLHA dermal fil-
ler formulations should focus on increasing the polymer
concentration and elasticity to improve the clinical persist-
ence. Ó 2008 Wiley Periodicals, Inc. J Biomed Mater Res
87A: 264–271, 2008
Key words: dermal fillers; hyaluronic acid; soft tissue aug-
mentation; oscillatory dynamic properties
XLHA fillers are more persistent than bovine colla-
gen,5 the differences among the various XLHA fillers
have not demonstrated obvious improvements in
performance. One recent study compared two XLHA
fillers, Perlane and Hylaform,6 and additional stud-
ies are expected as more fillers become available.7
Comparison of dermal fillers’ effectiveness is com-
pounded by the injection techniques,8 and the bio-
logical response of tissue to an implant in terms of
degree of inflammation.3
Here we compare the rheological properties of
several commercial XLHA dermal fillers to under-
stand the differences between them in terms of their
physical properties and to attempt to correlate physi-
cal properties with performance. One feature of hy-
aluronic acid (HA) that has been useful in some
medical device applications is its ability to form a
cohesive gel.9 Cohesiveness is a function of con-
centration and molecular weight. The property of
cohesiveness, although an advantage for certain
applications, is generally not an advantage as a
dermal filler9 because highly cohesive (HA) materi-
als are generally dilute solutions of noncrosslinked
HA with low elasticity and short persistence in use.
Dermal fillers are injected into the connective tissue
CROSSLINKED HYALURONIC ACID DERMAL FILLERS
of the dermis and therefore must be elastic in a low-
shear environment. It is hypothesized that elasticity
of a dermal filler leads to increased persistence but
comparisons have not been performed. For noncros-
slinked HA, dynamic rheological analysis demon-
strated that as the frequency decreases the elastic
properties decrease and hence, at low frequencies,
the material becomes less elastic, and more viscous.
Therefore, HA used in dermal fillers is always cross-
linked to form gel particles that have high elasticity
at lower frequencies.10 Dermal fillers prepared from
XLHA are predominately elastic at low-shear envi-
ronments and must have low viscosity under high
shear to be able to be delivered through a small-bore
needle. These unusual requirements have prompted
us to compare commercially available dermal fillers
prepared from XLHA in terms of their rheological
properties.
Clinical data comparing different XLHA dermal
fillers are only starting to become available in the lit-
erature. This study was undertaken to compare the
physical properties of currently marketed XLHA fill-
ers to determine which physical properties of XLHA
dermal fillers are responsible for effectiveness when
injected intradermally for soft tissue augmentation.
Since the clinical data directly comparing commer-
cial fillers to each other in the same study are not
available and most studies have compared a given
filler to bovine collagen in nasolabial folds in a split-
face design, we have confined our clinical data set to
using the wrinkle severity rating scale (WSRS) scor-
ing system for fillers used in clinical studies reported
to the FDA.11
MATERIALS AND METHODS
Materials
The dermal fillers were obtained from commercial sour-
ces. Restylane, Restylane SubQ, Restylane Perlane, Resty-
lane Touch, and Restylane LIPP were obtained from Q-
Med AB, (Uppsala, Sweden), or Medicis, (Scottsdale, AZ).
Hylaform, Hylaform Plus, Juvederm 24, Juvederm 24HV,
Juvederm 30, and Juvederm 30HV were obtained from
Allergan (Inamed) (Irvine, CA) or LEA Derm (Paris,
France). Puragen was obtained from Mentor (Edinburgh,
UK), and Esthelis Basic was obtained from Anteis S.A
(Geneva, Switzerland).
Rheological measurements
Small deformation oscillation dynamic rheological meas-
urements were carried out with a Thermo Haake RS300
Rheometer, Newington, NH, fitted in the cone and plate
geometry. All measurements were performed with a
35-mm/18 titanium cone sensor at 258C. Oscillation mea-
surements were made over a frequency range of 0.628–198
265
(rad/s). Percent elasticity is calculated as: Percent elasticity
5 (100 3 G’)/(G’ þ G@).10,12
RESULTS
The HA dermal filler formulations evaluated in
this study are all crosslinked. The exact nature of the
crosslinking reaction conditions, crosslinker type,
crosslink density, resultant particle size, and particle
shape, all affect the physical properties of the XLHA
formulation. While noncrosslinked HA forms a vis-
cous solution when dissolved in aqueous solvents,
chemically XLHA produces a material that swells in
aqueous solution but does not dissolve. Hence, the
XLHA dermal fillers are not solutions of XLHA but
suspensions of swollen XLHA particles in aqueous
solution. The properties of the XLHA products are
influenced by the XLHA particle size and amount of
polymer per unit volume. These materials do not
have a smooth appearance and depending on the
injection technique used can be lumpy. Also, suspen-
sions of crosslinked polymers require larger gauge
needles for injection into the dermis compared with
the solutions of noncrosslinked polymers.
Table I lists some properties of several commer-
cially available dermal fillers containing XLHA. The
source of HA is from bacterial fermentation except
for the Hylaform products where the source of HA
is animal (Avian). The crosslinkers used include
vinyl sulfone, for the Hylaform products, 1,4-butane-
diol diglycidyl ether (BDDE), for the Restylane and
Juvederm series as well as Esthelis Basic. Puragen is
crosslinked with 1,2,7,8-diepoxyoctane (DEO). Much
has been written concerning the nature of the cross-
linking reactions of XLHA dermal fillers. The differ-
ences in the products from different manufacturers
are generally ascribed to the physical state of the
swollen gel after crosslinking HA. Products are
described as being single or double crosslinked; par-
ticulate or nonparticulate; monophasic, or biphasic.
The Restylane, Juvederm, and Esthelis Basic prod-
ucts all use BDDE as the crosslinking agent for HA.
In the Restylane series, the crosslinking reaction pro-
duces particles of crosslinked HA that are swollen in
the aqueous phase. The number of particles/mL
and the size of the particles differentiate the prod-
ucts. As the size of the particles increases the num-
ber of particles/mL decreases, and the products are
advertised for use in the correction of deeper facial
defects. The number of particles/mL for some of the
Restylane family of products is listed in Table I.
The crosslinking reaction for the Juvederm family
of products is a patented process that produces a
single phase, nonparticulate, crosslinked HA gel
according to the manufacturer. This crosslinking
technology is reported by the manufacturer to give
Journal of Biomedical Materials Research Part A
266 FALCONE AND BERG

Size (ga)

BDDE: 1,4 butanediol diglycidyl ether, CPM: cohesive polydensified matrix technology results in monophasic double crosslinked HA, DOE: 1,2,7,8-diepoxyoctane—
Juvederm a softer feel when injected into the dermis

Lg. bore
Needle

30
27
30
30
27

27
27
27
30
27
27
27
and good persistence without the stiffness of other
XLHA dermal fillers. Esthelis Basic products use a
proprietary technology, cohesive polydensified ma-
trix (CPM) to produce a single-phase nonparticulate
XLHA dermal filler according to the manufacturer.

Medium to deep wrinkles and lips

Puragen uses DEO in a double crosslinking reaction
that results in both ether and ester bonds crosslink-

Mid or deep dermis and lips

Moderate to severe wrinkles
Moderate to severe wrinkles

Moderate to severe wrinkles

Medium to deep wrinkles

ing HA chains. According to the manufacturer, this
(EU) CE Mark

highly crosslinked material is expected to improve

Indication

Deep dermis and lips

Mid dermis and lips

Mid dermis and lips

Mid dermis and lips

the persistence of the Puragen products. The concen-
SubQ, add volume

trations of XLHA in these formulations varies from

Superficial lines

5 mg/mL to 24 mg/mL. Increasing the concentra-

tion of XLHA above
25 mg/mL becomes problem-
atic because the products become too difficult to be
Lips

injected through a small-bore needle.

Table II lists some rheological properties, at 0.628
(rad/s), of several commercially available dermal
fillers containing XLHA. The magnitude of the com-
Particles/mL

plex viscosity (|h*|), at 0.628 (rad/s) of the dermal

1000
500,000
100,000
10,000
No. of
The Physical Properties of XL HA Dermal Fillers

filler formulations, Figure 1, varies widely from 58

ND
ND
ND
ND
ND
ND

to 1199 Pa s, almost 20 fold. Restylane LIPP has the

double crosslinked—both ether and ester links formed during crosslinking reaction, ND: not determined.

highest magnitude of complex viscosity, 1199 Pa s

and Esthelis Basic, using the CPM technology, the
lowest. The XLHA products have a wide range of
complex viscosities at low frequency.
crosslinked
Vinyl sulfone
Vinyl sulfone

DEO, double
BDDE, CPM
Crosslinker

The magnitude of the complex viscosity, |h*|, for

TABLE I

the Restylane family of products varies from 330 Pa

BDDE
BDDE
BDDE
BDDE
BDDE
BDDE
BDDE
BDDE
BDDE

s for Restylane SubQ to 1199 Pa s for Restylane

LIPP. For the Restylane family of products, the rheo-
logical properties could be affected by the number of
XLHA particles contained per milliliter in the prod-
uct. The rheological properties of Restylane SubQ,
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Source

Avian
Avian
HA

Restylane Perlane, Restylane, and Restylane Touch

were measured and the results indicate that
although the number of particles/mL changes and
the products all have different particle sizes, and
indications for use of these products are different,
Concentration
(mg/mL)

Table I, the magnitude of the complex viscosities for

4.5–6.0
4.5–6.0
20
20
20
20
20
24
24
24
24
25

all of these products are similar. Restylane Touch

has 500,000 particles and a magnitude of complex
viscosity of 422.5 Pa s, Restylane has 100,000 par-
ticles/mL and a magnitude of complex viscosity of
532.4 Pa s, and Restylane Perlane has 10,000 parti-
Manufacturer

cle/mL with a magnitude of complex viscosity of

Q-Med AB
Q-Med AB
Q-Med AB
Q-Med AB
Q-Med AB
LEA Derm
LEA Derm
LEA Derm
LEA Derm

486.4 Pa s. The |h*|, at 0.628 (rad/s), for these

Inamed
Inamed

Mentor
Anteis

Restylane family of products does not relate to the

Q-med product literature.

number of XLHA particles contained per milliliter.

Figure 2 demonstrates that for the Restylane family
products, Perlane, Restylane and Restylane Touch,
all have similar percent elasticity that is not a func-
Restylane Perlanea

tion of the number of particles/mL. A change in

Restylane Toucha

Restylane SubQa

Juvederm 24HV

Juvederm 30HV
Restylane LIPPa

number of particles/mL from 106 to 104 per mL is

Hylaform Plus

Esthelis Basic
Product

Juvederm 24

Juvederm 30

not associated with a significant change in the per-

Restylanea
Hylaform

Puragen

cent elasticity indicating that the percent elasticity

for the product is independent of number of par-
a

ticles/mL and hence particle size.

Journal of Biomedical Materials Research Part A

CROSSLINKED HYALURONIC ACID DERMAL FILLERS 267

TABLE II
The Rheological Properties, at 0.628 (rad/s) of HA-Based Dermal Fillers
Product |h*| (Pa s) |G*| (Pa) |J*| (1/Pa) tan (d) % Elasticity

Puragen 941.8 591.7 0.0017 0.24 80.4

Hylaform 136.4 85.7 0.0117 0.14 88.0
Hylaform Plus 108.2 68.0 0.0147 0.11 89.9
Restylane LIPP 1199.0 753.5 0.0013 0.18 84.9
Restylane 532.4 334.5 0.0030 0.28 78.2
Restylane Perlane 486.4 305.6 0.0033 0.30 77.2
Restylane Touch 422.5 265.5 0.0038 0.32 75.6
Restylane SubQ 330.4 207.6 0.0048 0.39 71.8
Juvederm 30HV 81.89 51.46 0.01943 0.27 78.7
Juvederm 24HV 151.5 95.2 0.0105 0.31 76.2
Juvederm 30 93.9 59.0 0.0170 0.35 74.1
Juvederm 24 58.4 36.7 0.0272 0.53 65.2
Esthelis Basic 61.6 38.7 0.0258 0.70 58.8

For the Juvederm family of products, the |h*|, at
0.628 (rad/s), varies from 152 to 58 Pa s, Figure 1.
The magnitude of the low frequency complex viscos-
ity increases for Juvederm 24, to Juvederm 30HV,
next is Juvederm 30, with Juvederm 24HV having
the highest magnitude of |h*|, and the products are
intended for different indications. However, Juve-
derm 24HV and Juvederm 30HV are stated to have
higher viscosities and perceived to be the most
persistent of the Juvederm products even though
the magnitude of the complex viscosity, |h*|, of
Juvederm 30HV is no higher than Juvederm 30.
Although the magnitude of the complex viscosity of
Juvederm 24 HV is higher than Juvederm 24, the
magnitude of the complex viscosity,|h*| at 0.628
(rad/s), are all below 200 Pa s for this family of
products. Again, the magnitude of the low frequency
complex viscosity does not seem to correlate to per-
sistence or indicated use for the Juvederm family of
products.
The magnitude of the complex rigidity modulus,
|G*|, at low frequency, 0.628 (rad/s), for all prod-
ucts is listed in Table II. The magnitude of |G*| at
low frequency relates to the overall stiffness of the
dermal filler at low deformation rate. The magnitude
of the complex rigidity modulus, |G*|, versus fre-
quency, for the dermal fillers is shown in Figure 3,
and the higher the magnitude of the complex modu-
lus, the stiffer the material. There is a large range,

10-fold, in the magnitude of the complex modulus
versus frequency response of the XLHA dermal fill-
ers studied here. Puragen has the highest magnitude
of stiffness and Juvederm 24 or Esthelis Basic has
the lowest magnitude of stiffness. The Restylane
family of products has higher magnitudes of com-
plex modulus than the Juvederm family of products.
For the Restylane and Juvederm product families,

Figure 2. A plot of the percent elasticity at 0.628 (rad/s),

Figure 1. A plot of the magnitude of the complex viscos-
ity, |h*| (Pa s), at 0.628 (rad/s) for the XLHA dermal fill-
ers listed in Table II. The magnitude of |h*| varies widely
from 1199 to 58 Pa s for these products. Puragen and the
Restylane series have the highest magnitudes of complex
viscosities while Hylaform, Juvederm, and Esthelis Basic
have much lower magnitudes of complex viscosity.
(100 3 G’/(G’ þ G@), versus the number of particles con-
tained per milliliter for Restylane Touch, Restylane, Resty-
lane Perlane, and Restylane SubQ. The data indicate that
there is no correlation between the percent elasticity and
the number of particles/mL and hence, the particle size in
this Restylane product series. For this Restylane family of
products, the number of particles/mL do not correlate to
any of the low frequency (0.628 rad/s) rheological parame-
ters listed in Table II.

Journal of Biomedical Materials Research Part A

268
Figure 3. A plot of the magnitude of complex modulus,
|G*| (Pa), versus frequency for the dermal filler listed in
Table II. In this figure, Hylaform Plus and Restylane LIPP
have been omitted. In this figure, the legend order is in de-
scending magnitude of |G*| at 0.628 (rad/s). Puragen has
the highest magnitude of |G*|at 0.628 (rad/s) and Juve-
derm 24 has the lowest magnitude of |G*|at 0.628 rad/s.
For this set of products, the magnitude of |G*| varies
over 10 fold from the stiffest material, Puragen, to the least
stiff, Juvederm 24. The magnitude of the modulus or over-
all stiffness for these products is probably due to the cross-
link density. It is also of interest to note that although they
have different magnitudes, the slope of the |G*| versus
frequency curves is very similar for all of the XLHA prod-
ucts described here. This is not surprising since the struc-
ture of the crosslinked polymer swollen in the matrix is
very similar for all XLHAs.
the magnitude of the complex rigidity modulus
is more similar within each family than between
families.
Several studies concerning XLHA products have
referred to a rheological property called the percent
elasticity.10,12,13 In these studies percent elasticity is
calculated as (100 3 G’)/(G’ þ G@) and is reported
as the proportion of elasticity in an XLHA formula-
tion. The percent elasticity versus frequency, for the
XLHA dermal filler materials, is shown in Figure 4.
The XLHAs have percent elasticity that range from
60 to 90% with the Restylane series more closely
grouped than the others. There is a considerable
range in the percent elasticity of the XLHA products
with Juvederm 24 and Esthelis being the least elastic
and Hylaform the most elastic.
The magnitude of the complex compliance, |J*|,
versus frequency, for these materials, is shown in
Figure 5. The compliance is the inverse of the modu-
lus, and is a measure of how easy it is to deform a
material. Again, the data indicate that the XLHA
dermal fillers have a wide range of magnitudes of
complex compliance of over 10 fold. Puragen has the
lowest magnitude of complex compliance of all the
dermal fillers studied here.
Journal of Biomedical Materials Research Part A
FALCONE AND BERG
Figure 4. A plot of the percent elasticity, (100 3 G’/(G’ þ
G@), versus frequency of the dermal fillers listed in Table
II. In this figure, Hylaform Plus and Restylane LIPP have
been omitted and the legend order is in descending per-
cent elasticity at 0.628 (rad/s). Hylaform has the highest
percent elasticity at 0.628 (rad/s) and Esthelis Basic has
the lowest percent elasticity at 0.628 (rad/s). The percent
elasticity for these XLHA products varies widely from

60 to 90%. Since Hylaform has the highest percent elas-
ticity but the lowest 6-month improvement WSRS scores,
(see Fig. 6), percent elasticity of the XLHA dermal filler
itself does not correlate to product persistence and concen-
tration must be taken into effect.
Figure 5. A plot of the magnitude of the complex compli-
ance, |J*| (1/Pa), versus frequency of the dermal fillers
listed in Table II. In this figure, Hylaform Plus and Resty-
lane LIPP have been omitted. The magnitude of |J*| is a
measure of the overall ease of deformation of a material
and hence, a material with a lower magnitude of complex
compliance is harder to deform than a material with a
higher magnitude of complex compliance. In this figure,
the legend order is in descending complex compliance at
0.628 (rad/s). Puragen has the lowest compliance and is
the most difficult to deform, at 0.628 (rad/s). Juvederm 24
has the highest magnitude of |J*| and is easiest to deform,
at 0.628 (rad/s). The magnitude of |J*| for these XLHA
products varies widely (
10 fold). Puragen is the least
compliant dermal filler followed by the Restylane products
all of which have a magnitude of |J*| below 0.01. The
remaining products all have a magnitude of |J*| above
0.01 at 0.628 (rad/s).
CROSSLINKED HYALURONIC ACID DERMAL FILLERS 269

TABLE III TABLE V

Effectiveness Data for Dermal Fillers at Correlations from Tables III and IV
6-Month Post-Treatment WSRS
6-Month Improvement
Improvement Score Concentration % Complex Complex
Product Score WSRS Reference (6 months) (% Solids) Elasticity Viscosity Modulus

Zyplast 0.36 Restylane control 0.4 0.5 88–89 136 68–85

Restylane 0.93 Ref. 14 0.93 2.0 71–78a 330–530a 207–334a
Zyplast 0.5 Juvederm 30 control 1.4 2.4 65–76 58–151 36–95
Juvederm 30 1.4 Ref. 7 a
Excluding Restylane LIPP.
Zyplast 0.3 Juvederm 24HV control
Juvederm 24HV 1.3 Ref. 7
Zyplast 0.4 Juvederm 30HV control
inversely to the percent elasticity as shown in Figure
Juvederm 30HV 1.4 Ref. 7
6. Hence, as the percent elasticity increases, the per-
In these studies all of the XLHA products were com- sistence decreases. From the previous discussion,
pared to Zyplast as a control. this result is counterintuitive and indicates that high
elasticity alone cannot account for the persistence of
In attempting to account for any relationship XLHA dermal fillers; however, the concentration of
between rheological properties and clinical benefit or polymer was not taken into effect. The effectiveness
persistence, the available data are quite limited. This of the dermal fillers listed in Table V does correlate
is because few studies compare one filler to another. to the concentration of polymer in the formulation
Some fillers like Esthelis and Puragen have no as shown in Figure 7. Here, the persistence of der-
published data on performance. The available data mal filler is directly related to the mass of polymer
on fillers where one product was compared with in the formulation. Intuitively, it would be reasona-
another is summarized in Tables III–V. The data set ble that both polymer concentration and elasticity
is only for the clinical studies involving filling the would relate to the effectiveness of dermal filler.
nasolabial folds in studies submitted to the FDA in This relationship is shown in Figure 8, where effec-
support of approval of a Premarket Application. tiveness for a series of dermal fillers is plotted versus
Only the 6-month data point was evaluated in each
of the studies. If one compares the persistence of the
fillers for which there are data with the measured
values given in Table II, the persistence, as measured
by the 6-month WSRS improvement score, correlates

TABLE IV
Effectiveness Data for Dermal Fillers
at 3-Months Post-Treatment
3-Month
Improvement
Product Score WSRS Reference

Zyplasta 1.2 Hylaform control

Hylaforma 1.1 Ref. 15
Zyplast 1.0 Juvederm 30 control
Juvederm 30 1.6 Ref. 7
Zyplast 1.0 Juvederm 24HV control Figure 6. Described in this plot is the relationship of the
Juvederm 24HV 1.7 Ref. 7 6-month improvement score WSRS to the XLHA polymer
Zyplast 0.9 Juvederm 30HV control percent elasticity at 0.628 (rad/s), for Hylaform, Restylane,
Juvederm 30HV 1.6 Ref. 7 Juvederm 24HV, Juvederm 30, and Juvederm 30HV. The
Hylaforma 0.8 Control for Hylaform Plus improvement scores are from Tables III and IV. The WSRS
Hylaform Plusa 0.9 Ref. 15 score is a measure of the relative effectiveness of these
XLHA dermal fillers after 6 months. For these XLHA der-
a
To compare Hylaform and Hylaform Plus to the mal fillers, the WSRS improvement score increases as the
products in Table III, studies comparing Hylaform and percent elasticity decreases. The WSRS improvement score
Hylaform Plus to Zyplast are compared. In these studies, correlates in a linear manner to the percent elasticity at
a 6-point scale with a live evaluator was used to score the 0.628 (rad/s). Since the prevailing theory suggests that
3-month time point in the 3-month study demonstrating higher percent elasticity results in dermal fillers with
that Zyplast, Hylaform, Hylaform Plus are all similar. higher persistence, this result is somewhat counterintui-
Since Zyplast was used as a control in the Restylane and tive. These data suggest that high elasticity at low fre-
Juvederm studies in Table III, Juvederm, Restylane, and quency is not the only factor affecting persistence for
Hylaform can all be used to estimate effectiveness. XLHA dermal filler.

Journal of Biomedical Materials Research Part A

270
Figure 7. A plot of the 6-month improvement score
WSRS versus XLHA polymer concentration (mg/mL) for
Hylaform, Restylane, Juvederm 24HV, Juvederm 30, and
Juvederm 30HV. The improvement scores are from Tables
III and IV. The WSRS score is a measure of the relative
effectiveness of these XLHA dermal fillers after 6 months.
For the data shown here, the Hylaform 6-month WSRS
score was assumed to be equivalent to the 6-month WSRS
Zyplast score (Table III), because when Hylaform and
Zyplast were compared in a 3-month study, they had very
similar WSRS scores. Zyplast was also used as the control
in the 6-month study comparing Restylane to Juvederm.
For these data, the 6-month WSRS improvement score cor-
relates very well to the concentration of XLHA contained
in the product.
the product of the polymer concentration in solution
and the percent elasticity, at 0.628 rad/s, of the for-
mulation. All of the XLHA fillers for which there are
clinical data correlate linearly with the polymer con-
centration and elasticity.
DISCUSSION
The clinical persistence and characteristics of HA-
based dermal fillers may be influenced by their
physical properties.16 When HA is formulated as a
biomaterial for a specific indication, it is frequently
crosslinked.10 HA is subject to degradation by hyalu-
ronidase in the body and crosslinking is expected to
reduce susceptibility to enzymatic degradation. The
dynamic rheological properties of HA need to be
improved for the polymer to perform its intended
use as dermal filler. Crosslinking the polymer
increases the elastic modulus of the polymer, at low
frequency, making the XLHA more elastic than non-
crosslinked HA. Hence, for dermal filler formula-
tions, HA is chemically crosslinked to increase the
elastoviscous properties and increase the residence
time at the site of injection.
The advantage of comparing a series of dermal
fillers manufactured from the same material, that is
Journal of Biomedical Materials Research Part A
FALCONE AND BERG
HA, is that one can assume that the biological or tis-
sue response is similar for each filler in the series.
Many different filler materials have been tested and
the differences in tissue responses and injection tech-
niques make it very difficult to correlate the clinical
persistence of these different materials to physical
properties (for reviews, see Refs. 1, 17–20). Attempts
to compare the available XLHA dermal fillers have
been limited. Two products Hylaform and Restylane
have been compared in terms of some chemical
properties16 but since these products differ in con-
centration and particle size, the data set is too lim-
ited to draw conclusions. Rheologically, all of the
XLHA products generally have high elastic to loss
modulus characteristics exemplified by low tan (d) val-
ues throughout the entire frequency range. Attempts
have been made in the past to estimate the elastic
nature of XLHAs by calculating the percent elasticity
from the viscoelastic modulii. This approach is lim-
ited by the effect of concentration of the polymer.
Hylaform is highly elastic but is dilute compared
with other products and also is less persistent than
Restylane and Juvederm (Table V). Another possibil-
ity is that the magnitude of the complex viscosity or
the magnitude of the complex rigidity modulus is
the controlling factor. Juvederm has magnitudes of
complex viscosity and complex modulus that are
considerably lower than Restylane (Table II), and it
appears to be more persistent (Table V).
Other suggestions have been that the persistence
is proportional to particle size. The only product
family where particle size is estimated is the Resty-
lane family of products, and for this family there
Figure 8. This figure describes the correlation of the 6-
month WSRS improvement score to the product of the
concentration (mg/mL) and percent elasticity for XLHA
dermal fillers Hylaform, Restylane, Juvederm 24HV, Juve-
derm 30, and Juvederm 30HV. There is a linear correlation
that indicates that both properties (concentration and elas-
ticity) are factors influencing the persistence of XLHA der-
mal fillers.
CROSSLINKED HYALURONIC ACID DERMAL FILLERS
appears to be no correlation between particle size
and percent elasticity (Fig. 1), the magnitude of the
complex viscosity (Fig. 4), the magnitude of the com-
plex modulus (Fig. 5), or percent elasticity (Fig. 6).
The major difference between members of the Resty-
lane family of products with different particle sizes
is the injectability of the products. Restylane and
Restylane Touch are administered through 30 gauge
needles whereas Perlane requires a 27-gauge needle
and SubQ requires a larger cannula. Unfortunately,
comparisons of persistence among the Restylane
products are not available.
In conclusion, the oscillatory dynamic rheological
properties of XLHA dermal fillers have been deter-
mined and it was found that they are quite variable
with respect to the magnitude of the complex rigid-
ity modulus, overall stiffness (|G*|), the magnitude
of the complex viscosity (|h*|), and percent elastic-
ity. Although there are limited controlled clinical
data, the most straightforward correlation is between
persistence of the product and polymer concentra-
tion, when the products are compared in a typical
clinical study of paired bilaterally placed fillers in
the nasolabial folds. Within the same concentrations,
persistence appears to be related to elasticity. A lin-
ear correlation exists between persistence and poly-
mer concentration and also between persistence and
the polymer concentration and elasticity. The data
presented here indicate that the persistence of XLHA
dermal fillers appears to be a function of the concen-
tration of polymer in solution and to a lesser extent
the elasticity of the material. The maximum concen-
tration of XLHA polymers in the current XLHA der-
mal filler formulations appear to be limited to
25
mg/mL. Finding new methods to increase the
XLHA concentration in dermal filler formulations
may be the important hurdle to overcome for new
filler candidates prepared from XLHA.
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